Abstract Adverse outcomes, including death, respiratory failure and renal failure, are common after surgery, and represent a serious public health challenge. Such adverse outcomes can be mitigated through integrated, collaborative health information technology solutions that provide clinicians cognitive and computational support. The chief motivation for the TECTONICS (Telemedicine Control Tower for the OR: Navigating Information, Care and Safety) trial is that a multi-faceted telemedicine solution has the potential to facilitate the dynamic assessment of risk, diagnose negative patient trajectories, and implement evidence-based practices. The net result for patients would be improved safety and outcomes. Our telemedicine solution, called the Anesthesiology Control Tower (ACT), encompasses real-time patient data integration from the electronic health record, clinician decision support, machine learning algorithms that predict adverse outcomes, and remote monitoring for the operating room (OR). This conceptualization of sophisticated remote monitoring for the OR is somewhat analogous to an air traffic control tower for a busy airport. The innovative TECTONICS trial will build on a series of preliminary studies (funded by the Agency for Healthcare Research and Quality, and the National Science Foundation) that have (i) established the usefulness and usability of a prototype telemedicine ACT; (ii) customized and enhanced decision-support alerts for the ACT, based on clinician user feedback; (iii) designed, developed, and tested machine learning algorithms that predict adverse postoperative outcomes; and (iv) established the feasibility of conducing a real-world randomized trial of the prototype ACT. The TECTONICS trial builds logically on these preliminary studies. Aim 1 is to show that we can implement and sustain an integrated ACT system. As part of this, we will iteratively assess the accuracy of our machine learning algorithms and modify them to improve their ability to predict in real time when patients are at high risk for experiencing negative outcomes. Aim 2 is to understand how the ACT system affects clinicians? (anesthesiologists and certified registered nurse anesthetists [CRNAs]) thinking, decision-making and behavior. This understanding will help us to enhance the ACT system, improve workflow processes in the ACT and in the OR, and improve collaborative interactions between anesthesiologists and CRNAs. Aim 3 is to conduct a rigorous clinical trial. We will evaluate the impact of the ACT system on the quality of care in the OR, and clinical outcomes such as intraoperative awareness, and postoperative delirium, renal failure, respiratory failure, and 30-day mortality. TECTONICS will be the first practical and scientifically rigorous trial of a telemedicine solution for the operating room, and will inform the usefulness of incorporating such technology in routine care of surgical patients, including under-resourced healthcare settings. With many millions undergoing surgery yearly, this feasible application of technology could signal a major shift in the safety and quality of perioperative care, and translate into substantial societal gain.